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732 High Mortality and High Incidence of BI/NAP1 Clostridium difficile Infection in 27 Chicago-area Institutions

Sunday, March 21, 2010: 11:15 AM
Centennial I-II (Hyatt Regency Atlanta)
Stephanie R. Black, MD, MSc , Chicago Department of Public Health, Chicago, IL
Kingsley N. Weaver, MPH , Chicago Department of Public Health, Chicago, IL
Roderick C. Jones, MPH , Chicago Department of Public Health, Chicago, IL
Kathleen A. Ritger, MD, MPH , Chicago Department of Public Health, Chicago, IL
Laurica Petrella, BS , Hines VA Hospital, Hines, IL
Susan P. Sambol, BS , Hines VA Hospital, Hines, IL
Michael Vernon, DrPH , Cook County Department of Public Health, Oak Park, IL
Stephanie Burton, BS, MPH , University of Chicago Medical Center, Chicago, IL
Sylvia Garcia-Houchins, RN, MBA, CIC , University of Chicago Medical Center, Chicago, IL
Stephen Weber, MD, MSc , University of Chicago Medical Center, Chicago, IL
Mary-Alice Lavin, RN, MJ , Rush University Medical Center, Chicago, IL
Dale Gerding, MD , Hines VA Hospital, Hines, IL
Stuart Johnson, MD , Hines VA Hospital, Hines, IL
Susan I. Gerber, MD , Cook County Department of Public Health, Oak Park, IL

Background: Clostridium difficile infection (CDI) incidence, severity and mortality have been increasing over the past decade.  Since 1999, CDI discharge diagnosis rates have increased in Illinois.  The restriction endonuclease analysis (REA) type BI and North American Pulsed Field Type I (NAP1) strain has been identified in the Chicago area.

Objective: To describe incident CDI cases in Chicago healthcare institutions (HCIs) and assess infection control and laboratory practices.

Methods: A standardized questionnaire was completed for each CDI incident case during February 2009, defined by clinical symptoms and either the first positive C. difficile assay or more than 8 weeks since the last positive test or pseudomembranous colitis (PMC). Clinical and epidemiologic information was collected for each case-patient.  Toxin-positive stools of incident cases were characterized to determine strain type.  26 HCIs completed infection control and 23 facilities completed laboratory practice surveys.  

Results: HCIs completed questionnaires for 267 incident case-patients at 27 institutions.  Case-patient classifications according to standardized surveillance definitions are presented in the Table.  38 (14%) of incident case-patients had severe CDI defined by admission to intensive care, need for colectomy within 30 days of CDI diagnosis, or death with CDI. Bowel surgery was required in 6 (16%) of 38 patients with severe disease and 7 (18%) of 38 patients were found to have PMC on endoscopy or on pathologic specimens. 20 (7%) of incident case-patients died.  138 stool specimens from incident case-patients were typed, of which 61% demonstrated the BI/NAP1 strain. Individual HCI rates were defined as the number of incident cases of CDI with symptom onset after 3 days in the hospital per 10,000 patient-days during February 2009.  For those participating hospitals with CDI incident case-patients during the investigation period, rates ranged from 2-7 case patients per 10,000 patient days.  Of those hospitals with a hand hygiene policy when caring for patients with CDI, 65% required the use of soap and water while 35% allowed alcohol hand gel or soap and water.  35% of hospitals performed terminal cleaning with bleach in rooms previously occupied by patients with CDI, while 23% performed daily cleaning with a bleach containing product for rooms of patients with CDI. The majority of HCIs detected CDI by the EIA for toxin A and B.  Providers sent a median of 1 diagnostic test for CDI (range 1-7 tests) per patient.

Conclusions: CDI infection control practices varied between institutions surveyed.  CDI rates were within the expected range, but caused severe disease among 14% of case-patients and 7% mortality during the one month surveillance period. The BI/NAP1 strain has become the dominant type causing CDI in the Chicago-area.